chang on the idea of racial progress in america. on what makesson us human and different to other species. on american history tv on thean3, tonight at 8:00, social prejudice immigrants faced during the 1800s. sunday night at 8:00, the 20 than a verse or he of the fall of the berlin wall. find our television schedule at www.c-span.org. at 8:00, theht 20th anniversary of the fall of the berlin wall. join the c-span conversation. like us on facebook, follow us on twitter. institute of medicine recently hosted an ebola workshop at the national academy of sciences. doctors and other health professionals involved in the study and treatment of ebola presented research data on the disease and highlighted areas where more data was needed.

>> good morning. i and the president of the institute of medicine, and it is my great pleasure to welcome all of you to this very important meeting. i understand that as of yesterday, we have over 700 people registered. we've limited the size to 250 in order to be manageable in the breakout conversations so a lot of people are going to be here on the webcast. we are seeing the devastating effects of the virus outside of the united states because we are seeing it entered the united states as well. fortunately the public health system responds to the virus is robust and of the small handful of people with ebola in the u.s. only one has died.

in africa the picture is different. we have seen over thousands of cases and high fatality rates. we have just heard that the epidemic is still far from where we need to be. the cdc has predicted that in the worst-case scenario over many people could be affected by january, liberia and sierra leone. what went wrong? there are many lessons to be learned is that we can be better prepared in the future. among these in my opinion is that it needs to step up efforts to improve infrastructure globally. in fact they've recently released a report on the global health systems which make the case that strengthening the health system is the future of

global health. they wrote a powerful op-ed eliminating this issue you as a key factor in this crisis. the countries with the public health systems. even in the u.s. we need to pay considerable attention to how we identify and treat individuals with the virus and prevent the dissemination. it's the importance of having the robust preparedness hospital system and in addition it is important to ensure the guidance and actions are based on up-to-date scientific evidence we must do the best for patients, providers and society.

there are many scientific unknowns where we must put enormous effort we need to know more about the transition and activation and disinfection of the contemporary services. we also need to understand how the personal protective equipment can be best used by anyone that may be exposed to a virus and not just health professionals. so there's a lot of love since learned and there will be lots of opportunity to have that conversation discussion move forward based on what we've learned. so the secretary response together with the nih and cdc asks that we can could be in this workshop to provide

information about the scientific priorities on the disease. it is a trusted, independent space that people can debate many topics open my. we've developed the workshop to inform the public health communities of the research that needs to be performed to ensure that they are on the scientific evidence to inform the public health officials and providers and the public for the most current information about transmission and other measures that should be taken to prevent the spread of ebola. furthermore what must be performed now for the important specimens and information and data.

we should aim to have a system that allows us to collect and analyze data and provide advice in real-time. we will be addressing these in more detail so we need to listen to the various points of view and identify research needs and gaps. we are not here to provide a political advice at this time as that is not the intention of this workshop. we've opened this to the world through the webcast so that no matter where you are, west africa or the u.s. you can learn alongside with the participants.

we have over 700 people registered to watch today and the videos will be posted on our website for future reference. i want to put out a slide for the planning committee because they came together it. short time in order to do this to pull this together and because the chair and all the other people who i won't have time to read all the names. this is a workshop where therefore many of the researchers have come together to bring expertise to this issue. i like to acknowledge they brought up the policy, the population for the practice and the life sciences division of earth and life science studies. i also think so many of you that come from far and wide to present your research, viewpoint and expert advice to the direction of the research in this country. some were not able to make it because they were battling the

epidemic even as we speak and because our thoughts are with them today. we have a full day ahead of us and we will dive into several areas of the transmission routes cut survival of the virus can protective equipment and behavior, waste management and the methods and at the end of the day we will discuss the urgency of researching each topic. so i think that this workshop is timely, important and an exciting moment. we are advising the direction of research where the government and other dollars should be spent spent to send the conversation to be taken lightly. i would like to turn over to doctor goldman who is the chair of the planning committee in a meeting and she will make some remarks.

>> thank you so much to the planning committee. you've done a lot of work in a relatively short pier, tim and i appreciate the volunteerism of love with the speakers who are with us today, but the facilitators and all of you for being in attendance. the other toward him at the national academy and also online. you will contribute in many ways to this discussion and i appreciate that. the workshop format and the purpose is to foster dialogue about the research priorities but of course not to provide a recommendation. we do the leave that it's possible to help foster research during a response to inform the practice and also ensure guidance in the future is based on the most current science and to make sure the data is

gathered before they are launched. the research will help inform public guidance and critical guidelines but we are not here to review those or participate in developing them. so the outline for the day is that we will begin with some plenary talks that will help us come to a common understanding about the -- it has already established in this area as well as understanding the potential gaps that exist and then we will split into four breakout area is one on transmission routes and exit for the ebola a virus into the second on the insect in the environment and a third on personal protective equipment and personal behavior to prevent transmission and reduce exposure to the ebola virus and the handling of potential contaminated materials.

we know that health care workers are at risk and this shows the epidemic transmission diagram from the cases that occurred earlier this year in nigeria. on this side are the blue health care workers and responders of all kinds whether kind whether they are health care workers or family care providers that have been particularly at risk requiring this disease so we know that the workforce is at risk. when we think about the risk like this in the context of protecting the workers, we are thinking about exposure and at the concept of exposure has to do with the contact between the outer boundary of the human body and the public and one extra of pollutants in this case the virus such as the ebola virus that requires the presence of

the pollution and actual contact with it and usually a quantification of the amount of the pollutants and the kind of contact this is how this is normally done. so the whole paradigm for the environmental health has to do with looking at agents such as either biological fluids or an all-around server or is and exposure routes in the case of needle sticks or respiratory perhaps and biological response such as infectious disease and/or just any responses to that infection. >> in that framework what is the agent and we are going to learn more later today about this agent on the ebola virus and it's very interesting and dangerous.

when we think about how people might have contact with it what is important to understand and this is important in the epidemic in sierra leone that documents a fair portion of the case of diarrhea and vomiting and a smaller proportion cough and so these are three ways that awfully fluids are certainly going to potentially be involved with caregivers. animal hosts are another question. we know in the situation in africa but there are animals involved into the don't know how those dynamics work in the ecology of the disease but we don't know if they are potential risks with companion animals and

so there's been a little bit of a question about what to do with companion animals into this is simply a picture of one of the nurses with her dog both of whom sent home on friday and the other one after being quarantined for 21 days. so there are basic strategies and public health he is to prevent injury and people from receiving harm and the environment and arranging from of course trying not to create a hazard of the first place of reducing or preventing or modifying a hazard all the way through some of the things that could be done in the future like increasing resistance and improving emergency response and care and rehabilitation. but here we are really focused on these three things in the middle ground, separating time and space and modifying the

basic structures and finding ways to separate people who might be at risk from the hazard it in particular we are most concerned about again responders and care providers of all kind whether occupationally involved in providing care or family members. and when we think about occupational exposures and potential interventions that we can use to get lemonade or reduce exposures, we think about these as occurring on the hierarchy where we know that it is far more efficacious if we can engineer the environment or change the process to prevent the possibility of exposure in the first place, less effective is to take administrative for programmatic behavioral approaches where we try to change the way that people work

together, the behavior of the cases and the least efficacious they use a personal protective equipment. this is a personal protective equipment is really considered to be a last resort, but something that is very, very necessary if there is no way to protect people through engineering or administrative approaches. we have a lot of information and there are existing criteria. we are here to review the spec just to remind you we are not starting from ground zero. these are the protocols that every university currently has on their website which are labeled draft, which i think that means even for emory is experienced with treating these kinds of illnesses. we currently have waste

management protocols. we have the u.s. department of transportation has many regulations and there's an enormous patchwork of state and local regulations about the management and handling of the bio hazardous waste. at the same time the few cases that we have in the united states have posed in the challenges in terms of the quantities of the ways that have been generated. on the one case the entire truck pulled up after the appointment to haul off the waste and in dallas with one patient 140 barrels 55-gallon barrels were generated and in fact there were controversies about how the ashes were incinerating the waste would be handled in for

the competing not to take those actions so we will produce a workshop report that will be prepared by the institute of medicine. this will be publicly available what transpired here at the workshop. there will be further deliberations by the planning committee. what will be in the report well emerge from what the speakers at the workshop brings forward. it will be published by the national academies and the decent ideas will be those that the workshop participants and lost the national academies of the planning committee and there will be no former consensus findings and recommendations coming from this activity. >> said, with that and to conclude once again by being here i would now like to turn to doctor the coal who is the

assistant secretary for preparedness and emergency response at the department of health and human services, and she will give you a perspective from the standpoint of her agency for this workshop. thank you for being here. >> thank you to all of you for coming. in. and for tuning in on the web and other ways. and thanks very much to the planning committee for rapidly putting this together. i thought that i would take a quick step back and get a bit of perspective. i came into this position in 2009 just as the h1n1 was ramping up. i ended up on a phone call around the country each talking about the temptations that are in the icu. and a group of us listened to them and thought if we could get

a download of cases to this it should be possible that if people survive this disease we go out to the nih research network and to entity agreed to modify the protocols for sending the identified data and we felt that we were on our way. it turns out that it took six months for the human subjects committee of the respective universities to approve the changes to the protocol and we completely missed the window to know how fast to treat people. 18 months later we learned from the work that about 40% of the children who died died right from the resistant staph and not from h1n1. and it was with that that i said we are not as equipped as we need to be to do science and to

do the kind of research that needs to be done in an emergency either to affect the course and trajectory of the emergency or to be sure that we are never in the same situation twice. it's in the spirit that we are holding the workshop today. my office has launched a fairly comprehensive science response initiative which is now across the hhs. one immediate outcome is that there is a public health emergency and it is they send that it could be used in an emergency. another immediate outcome of that work has been a process that is set up in a meeting. in any emergency it's important to get the groups of experts together not only inside of the government but outside of the government to identify with the research priorities are for the

consideration review. so in that spirit we have a standing arrangement in the institute of medicine so that in the event of an emergency or disaster or another public-health crisis we can ask them to convene a group of experts that would be you and other interested parties to help identify what the research priorities are that well help manage this event and not be in the same situation the next time there's a lot of science already going on and i don't want you to think that there isn't. for example, the same candidates are promising and are now finishing the safety studies that and i each at walter reed and hopefully will go into clinical trials in west africa in december. a number have been developed and are in various phases the various phases of testing and will be subject we expect to the rigorous clinical trials.

those are not the focus. similarly the group has put together a finishing the development of the practice guidelines. i want you to understand that is the kind that science is going on and it does not need to be the focus here. but the focus really needs to be on impacting the public health and medical response for this and for the future. during the people are rising or after deepwater horizon, we put together the different federal agencies that were involved in doing the research during that event. we learned that there were 17 different federal agencies all of whom were involved in research or science or one way or another they largely didn't know about one another. and because of the way that they collected a lot of the data it

became very difficult to leverage all of the tremendous work that has been done. in this event under the auspices of the office of the science technology policy at the white house all the different agencies ranging from hhs to the department of transportation to the department of energy and beyond have come together to identify what it is that they can bring to the site and what it is they are doing and identify both priorities and opportunities for the collaboration. however, we do need to hear from people outside of the federal government about this and that is a part of the genesis for this. when we planned this workshop we were in a very different situation in the epidemic and we are now. we have not yet had a case or cases in the united states and so we are going to be a little bit flexible today in terms of how we think about this agenda and how we identify together with the science parodies are but regardless we started seeing that the public and the

healthcare workers had many concerns about how to protect themselves but in west africa and here. environmental issues always come up in situations like this both to guide the public health response and to address the public concerns. i don't know how many of you saw the piece in the news this weekend about some of the challenges not only with the patient's apartment in dallas but the fact that right now the ashes remain in limbo because there's not any there is not any place that will accept them. in the interface between science and dealing with public policy and dealing with public concerns this is not an exercise in the could have come should have, would have. it's not an after action report and i want to stress that. i am hoping today that we can

focus on actual work. it will help us move forward to protect public health both here and potentially in west africa and work that should be prioritized now. i want to stress i'm working at this from the set of priorities and not just good issues and ideas. some of the prioritization process will have a time element. what needs to be done now eager to answer important questions or to be posed to answer those questions in the future and that involves the collection of data and specimens or whatever and it is both of the others let's keep in mind that this is a workshop. it's not a consensus process or process to develop the formal recommendations but it is a process to give us and federal government and the scientific communities around the world a sense of what you think the priorities are.

so thank you for being here and i look forward to the deliberations of the day. [applause] >> it's now my pleasure to bring forward the first speaker. the professor of medicine and director of the galveston national laboratory at the university of texas medical branch. he is going to talk to us today that the characteristics of the virus in the u.s. environment and what do we know and are there assumptions being made based on the science. thank you for being with us today. >> let me thank the organizers

for inviting me. but they say the disclaimers number one this is not a comprehensive overview. there are so many examples and we are all going to be talking about them so i apologize for those in advance. what is heavily influence on the experience since we worked through the key issues that we will be discussing today. i check the numbers and we had nearly four team thousand cases in the mortality rate of 70% said the outbreak is out of control going in the wrong

direction and i think that this is important to realize the number of health care workers is astonishing. it decimated and as a result of the international community's responsibility is to provide the resources. this feeds back into the national strategy on how we manage the returning volunteers and i think this is an important key to keep in mind. if we volunteer for a month overseas and then have to add three weeks in quarantine a lot of people will think twice and i think that this is a real issue. what is the risk of the introduction we are all aware of where it occurs. this is a recent publication just just on where the fights from africa go. and we got a whole lot of places including significantly to asia as well as europe, south africa and the united states.

so there is lots of opportunity for dissemination as we go forward. what are we really worrying about? there are maybe three groups of individuals we could consider into nationals. the local nationals, mr. duncan of think is a great example that category -- people that up e been infected and end on our shores. international travelers, there is a lot of business people going around the world. i am not aware of this example yet, but i do know that during sars we saw that on more than one occasion. finally, the returning volunteers and healthcare workers. these are the folks that are and ly in the news today an important part, not only for the response, but also for our national discussion as we

go forward. so what have we seen in the united states? have seen mr. duncan who arrived, was hospitalized at the hospital that was clearly unprepared. the ubmit to you that experience in dallas is exactly what would've happened in 99% of the other hospitals around the country. we simply were not ready. hospitals in general are not ready to manage this kind of a case. as a result, a couple of nurses became infected. they have now survived and were treated well at emory and nih. established to today's patients. we have seen five american were returned from africa back for treatment in to both ed states emory and nebraska.

the point here, and i will is that the er on, of ebola are aware cases are aware of it, they do a very good job. i'm virtually certain that they are a lot better prepared now than they were a month or two ago. that our last example is a healthcare worker who self -- follow the rules we articulated them -- as he became clinically admitted to hospital. it is not appear to be as great as we have feared, but to the best of my knowledge, we have found no secondary cases either the nurses or mr. duncan's family. you'll recall that mr. duncan quite ill at home, so there appears to be a standard

for transmission that is fairly significant. and have gone in decontaminated to residences that i am aware of. three of them. details o not know the on the 3rd nurse. in the case of mr. duncan's even took the toilet. 140 450 gallon ways taken -- 144 50 gallon drums of ways taken from their. medical waste from hospitals, medical waste from hospitals, we had nearly 150 gallon drums associated waste drums - 100 50 gallon associated with mr. duncan's case. a and then we artie heard little bit about the pets and how to manage the pets.

what have we learned? the ebola virus, we have not seen anything out of the ordinary. we have noticed the importance of ppe, obviously, and, specifically, we have seen importance of appropriate counting -- gowning to avoid contamination of our individuals. and rehearsing some challenges associated with cleanup of medical waste. so what is our national strategy? we are all aware that we are they enter eople as the country. africa, we are using traditional interventions, trying to separate those who are infected from those who are not infected. who has aggressively set up the the collaboration from

cdc exit monitoring, so that prior to leaving -- their to exclude any patients -- upon entry into united states, we are doing the same thing. in our discussion about how to quarantine is continuing. so this is fine for a focused outbreak that comes from west africa. were to become transmissible in, say, asia or another place, how would we manage that? i think that is a challenge we will hopefully not have to face. so what we know at this point? several hospitals are well prepared to safely manage ebola patients. clearly, we can do this if we know in advance. we run the greatest risk when the hospital does not know it is an ebola patient. all my gosh, we have had a problem down the road. we know that self managing works.

we have a few examples that were people have self to seek ed, gone clinical care, have been isolated and treated and have not resulted in secondary transmissions. think this is important as we go forward. there is no scientific or dence, so far, observation to support the risk of transmission prior to the onset of clinical symptoms. we have been fortunate in that the mortality rate has been much lower here than we seen in west africa and other african outbreaks, which tribute to our care -- our modern work. out of an abundance of caution, i have come to hate this phrase because -- you know it is going to follow after that. a o, we have referred to couple of examples. in my ost egregious one

mind is incineration does not necessarily kill ebola. just a footnote -- we had a briefing for the texas board of nations and i specifically said that incineration kills ebola. do so that there are no questions. the other one -- i'm sure you all have your examples, but school systems closed because flew on an airplane with someone who had ebola -- anyway, lots of issues. the whole discussion that do tinues today about how we manage travelers and what is the science behind this. and lots of discussion, lots of observations -- i'm not of these to d all you -- but you have all seen the headlines, i'm sure. then, the most recent, a nurse who said enough already. scientific basis

for this. nonetheless, in my opinion a welcome ation, push back on this ongoing discussion. of we have lots newsworthy issues here. comments from ibsa, they do not support mandatory quarantine. very thoughtful editorial -- this is from nbc news -- again showing why this is a bad idea. lots of discussion on this and it is not resolved. let me just touch on a couple of the scientific papers that i could come across from the basis of some of our discussions. saw sure that many of you

this most recent edition of the new england journal of medicine. i think this is 16 october. this is an overview of the situation in west africa. so let me draw your attention down here to the frequency, this is the incubation period. contact between index case and the onset of disease. you can see a nice curve here. 21 days as i cut off. there are a few cases which appear to occur after that. you'll recall the criteria for calling a country free is 42 days. everybody has always known that this is biological and there are some occasional outliers. is e numbers appear -- this 9.4 days average for incubation.. that is -- incubation period. with a paper by

tom. again, this is titers come in this case, of days post onset. nice data there. again a nice curve. followed by john towner's paper. is based on pscl -- a of the data ement -- but again you can see the curve is starting low and going up as the disease progresses. the open bars represent those who survived. you can see there is a strong correlation between viral load and the outcome of disease.

the assessment and risk of virus from bodily fluids -- then can explain a little bit more -- dan can explain a little bit more, but i wanted to highlight a couple of things. this column here is pcr positive. the bottom line is that they had 14 positive samples. bunch of a whole different categories -- stool, russell, mucus, and so on. is e center column here virus culture positive, and there were a total of four positive. importantly, of those 42 of specimens were convalescent -- one in semen and one in breastmilk. have not talked about the of transmission after recovery and i think this is something that needs a little further discussion. dan also did a very nice study one of the samplings of a

bunch of different sides and attempting both virus culture and pcr. lot of negatives there, so either they were very clean -- i will let him what that means -- but there were some positive both in they are bloodstained samples from doctors gloves and all that. many of you have seen his papers on the persistence of the virus in various services. highlighted here is ebola. this was looking at the survival of the virus overtime. -- i'm sorry urs -- this is 144 hours, and two logs the virus. so you can see that the virus survive for quite some time.

the study is based on the storage of material -- the scale here is in days. the important point is that all the results are at 4c. that, perhaps, a viruscan survive a little bit longer than one may presume. the 4c is significant because when we're dealing with all the medical waste from dallas, that was stored in a refrigerated truck at 4c. actually preserving the material. the slides ve seen are ready about the dog. is doing ely, bentley just fine. the only paper i could find that dealt with pets is one from the emerging infectious diseases that was published in 2005. this is from the group in this is only antibody

-- zero prevalence year. on controls from france and so, i am not sure how to interpret this, nonetheless, in ebola endemic villages, there were certain number of positive animals. i do not know whether that they shut the virus, but it is an area for further investigation. a lot about air transmission. this is the only data you are going to see. this is from our laboratory coincidently, had just finished an aerosol transmission from nonhuman primates. you can see it easily infected and killed nine nonhuman primates.

sure, have rl, i'm seen -- you have all, i'm have seen the article of is this airborne. an is is been through of human to nt human contact to air. unfortunately, we do not have that information. talked a lot about ppe and the importance of it. are photographs from 1995. you can see what was one of that time. another -- another photograph from there, i'm sorry. have seen the jama

a rticle are calling for review of ppe and new ppe equipment. i think this is, again, an area where we may very well benefit from further review of what is being done and other improvements to be made. okay, so what do you know? well, we have confirmed that the ious observations on lack of transmissibility -- there is no question in my mind that this is very important. we know that the risk of be mitigated an by ppe, but, we need to do it right. that is an area for continued investigation. and some simulation studies show that, can go a long ways. we don't know -- well,

the unprecedented impact of human to human transmission's, but i think this is significant and it reflects another problem that we have in that we not have access -- the global scientific community does not have access to the virus. so our research efforts are somewhat hampered. how to clean apartments -- we can clean them, but how clean much should we w do. this is ongoing. we have talked about that. the risks associated with domestic pets, clearly opportunities there. we do not have any diagnostics for them. and last but not least, we do not really have a good and how to communicate with the public. especially in the case of ebola. i think with that, yes, i'm done. thank you very much.

[applause] >> what we are going to do it is we're going to actually presentation a from our panel about the existing research landscap. then we're going to bring the speakers and the panel is back up to the states for some time questions and an action. is my pleasure to invest centers eaders from the of bio defense at the university of texas medical forward to ome talk about existing research ebola and on ongoing initiatives. >> thank you very much.

unfortunately, our information technology people of their eel like part mission statement is to be sure that nobody in the faculty can use the internet. so i do not have any slides. but let me tell you what i'm going to tell you -- what i to tell you, anyway. mission is to tell basically the truth, the whole truth, and nothing but the truth. has to include -- i don't know. work in that context, you'll find that you truth will be found to be wanting. i think -- truth -- is the incubation period. the incubation period is

advertised as 21.0 days, but in many of you have worked this area before will know, incubation periods are a distribution. and usually it is a longitudinal distribution. if you look on the internet for ebola incubation periods, you'll find a number of papers not only the law, but function and so on, and you'll find that the incubation period varies. basically the s longest interval that was cases in the n 1976 outbreak. almost a sure bet -- other calculations without -- that we will have someone who surpasses that incubation..

is would guess that there 5% of a 5% -- that about the people will be found to exceed the incubation period. what that will do for the media and the population, i do not know. to what will come back in the uc described communication strategy and someone will have to be thinking about that. the -- another thing that i to be thinking about is very soon there's to compare a need therapeutic modalities -- and will include drugs,

plasma, monoclones -- and this is going to go into nobody has hat talked about which is basic care. enable a ook at postmortem -- an ebola they are ostmortem, full of -- so you are left with a difficult situation. my thoughts would have been of fluid and ent electrolytes would probably not make a great deal of look at ce, but if you the cases that we have in this country, it apparently has. have had very low patient fatality rate share, compared to west africa. so i think that should be formerly looked at. other thing that is on the menu for treatment the question of

coagulation. to this is present in every place it has been tested. i think we can figure that this is one of the problems. how important it is, we don't know. we've done some studies actually s that have been in people -- it didn't for embolism -- but in very onkeys, it was advantageous in preventing coagulation and improve survival. monkeys you the the nematode ,

accessory protein -- that a very interesting outcome. they were lower than they were in the control group -- consistently and significantly lower. -- nic plays in with with virus production. but is not clear to me, perhaps it destroys sight of replication. it may act in the spleen to effective immune response, preventing clotting in the spleen. that for whatever reason, is something that is really to itself for disease for which we have no established therapy. speaking of established therapy, i am worried about two things.

one is, enthusiasm for potentially worthless products that have been given to going to who is survive anyway. well be may convalescence plasma because there is no experimental system where that really works. see suppression of viremia in monkeys getting up off the case for and walking. it e only report where it med to

seemed to work is a 1999 with some work that was done while we were there. one of the things that was most striking about that was that there, ate, or there were no controls --a, there were no controls. and, b, when you look at the desk, you son of these people were destined -- when you look at the people who survives, these were people who were destined to survive. late in the epidemic when deaths were somewhat less, they receive their convalescence blood at a time where most patients had artie declared whether they were

going to live or die -- already declared whether they were going to live or die. that has given rise to a lot of thoughts that i think of me to a lot of wasted effort. i believe that the -- the -- we should be better served by that ng some of the things i just mentioned, but if we do use convalescent plasma, than it should be subjected to rigorous tests like anything else. thinking he -- i am back to the symptom that was in the us -- but in a situation like this, people do not want to do a controlled trial. they do not realize that without a controlled trial, to bring never be able full force of you have been working with to bear on the disease. you'll now be able to get the not be able to get general acceptance. so i think it is very we support the drugs and the therapeutic that we propose by a controlled trial -- a controlled random trial. there are certain other obstacles to this and that is

this is not a common practice in africa. attitude that go y have when you try to administer your health in, sierra leone, the responses, well if it works, let's give it to everybody. and if it doesn't work, let's give it to everybody. i think that is a good philosophy, but you don't know you do it works until the trial. so we have to resist the to ulse and the pressures just pull something out of the freezer and use it. i guess -- one of the things that was on my list which, did not make the -- the electrons that i make the cross the wires -- was

issue of staffing. was going to do all the stuff? i don't think you want to pull a trial like nto this. problems of terrible with staffing -- others will talk about that later -- but be able recruit sampling who are capable of doing these trials. it also reminds me that one of the things we actually must fix to do the e have clinical virology of ebola. in other words, we have to understand the day by day, the production day by day, as well as excretion of the virus to the outside. i don't know if any of you in the en anything

literature about the titer of the virus and vomit. i would very much like to know. but if you look through the literature, that vomit is often the ways as one of to get infected. so i think we need backend of clinical virology. for that, we have to fix the export of samples. you can do that on the side, but that is not the same as infectivity. another related issues quarantine because if you do was on the outside -- if you knew what was on the outside of somebody -- you should think about quarantine and how effective it should be and how should it should be. well, many years ago, i work on an ivia to

outbreak of bolivian with rhagic fever interpersonal transmission and i can tell you several things that have run a bell with me. recently, one is i was living in panama and my wife worked in the clinical lab. clinical lab the said, oh, we are so sorry to see peters go. i think that is one of the don't want to send. think there have been -- to this. after the outbreak, i was boss by ting with my hand radio -- there is no no ernet at the time and telephone lines -- i noticed that when i was talking about coming back, he was strangely silent.

finally found an airplane that would break the strike, while i come to pass back to e, and i flew la paz and there i got back onto a military flight and discover that i was not wanted. panama didn't want me, the us didn't want me, the canal zone didn't want me. so i didn't know whether to take a backstroke out to sea or what to do. a very who was persuasive guy, persuaded them if i would ome back undergo a three-week quarantine. does this sound familiar? the laboratory had some rooms on the top floors. so i was to -- when i came out of the ushered

airport -- the fastest have ever ustoms i -- and put in the attic at our lab. it is not tell you, pleasant after you have had a you're ituation and wife g back and your and kids are brought back in you wave at them. but i think we should think about that when we look at guys who are returning and if they have significant exposure, like a needlestick, than i think they have to go for the quarantine. people who don't have highly dangerous exposures don't deserve to be locked up, given what we know -- or think we know -- about ebola. inevitably, there will be

some something that we have made that will turn out not to be true, but renault the dogma now, the dogma is the sick or you get, the more infectious to get. as far as that goes, it is one, faith. and two, if the initial growth is in the lymph node, and there is viremia viremia equently, this rescinds target organs and presumably this is the point where people become infectious. i do not think this is proven. it also raises the question of where is the evidence to back this up. the only thing i have been find is the study

that scott and several of us and looking lies to family ssion groups -- indexed patience -- and that show that there was little transmission, if early in the -- in the periods. the periods at home when they were sick, there were some transmission. still only about 25% of the contacts who were infected. so, i do not know how we're that to devise information strategy which will attack the public that dallas s if you go to and you come back, you should be quarantined.

but we need to do that and we need to look for a scientific basis for many of the things we're using. thanks. [applause] >> before a panel is dr. john howard. is the director of the national institute for occupational safety and health at the cdc. actually, dr. peters, if you can stay up you your -- we're going to bring up the other nametags. >> thank you very much. to thank the iom and the national research council for giving us all together. going to do today is a rather deep dive into five personal protective equipment knowledge generation along with three biological behavior priorities.

while today we are talking about ebola virus, i think it that all ant to note the issues that i am going to raise really have broader applications for pathogens. and, certainly, if we see in internationalization of of world in terms infectious diseases -- if we see more of these events, all of these issues are going to be actually important for us. so the five that our ppe issues. worker ow do we quantify exposure to match ppe with the level of exposure. research is needed to discern the protection methods? what are the most effective donning and doffing procedures? other novel ppe designs that will be more effective inpatient settings?

and lastly, it is not just fedex interested in logistics, we best understand the ppe system? first question, matching ppe with required level of exposure protection. issue is e proportional protection. i think it is an important one, it is an important research topic. and the point here wanted to emphasize -- the observation think is important -- we have done years of data in assigning the level of protection in industrial settings, but similar assessments are very complex in the healthcare setting and i do not think we have done a lot of research in that area. to do, certainly, more. research is done to the machine that ppe will protect workers. here we are talking about the scientific basis for validating, determining the test methods. a lot of ppe recommendations

are really not associated with a national standard, an international standard. there is a lot of concern whether an appropriate test method is being used to evaluate, for instance, permeation. so there's certainly a lot of what they can be done in this area. at niosh we are doing a lot of work at our personal protection laboratory. we have a sweating manikin that some of you have heard about. looking at each of the studies in determining the duration for worrying ppe. permeability studies to look at ppe. glove degradation in terms of of bleach and alcohol-based sanitization. what is the most in donning and

offering. use -- during use -- and especially during doffing. several speakers have spoken about this up before. it is extremely important to the events of contamination. the fourth issue, either novel pbe designs that would be more healthcare for workers to use in patient care settings. these are very unique settings and they are very stressful both for the provider as well as the patients involved. president obama announced a grand challenge to improve pbe while back -- ppe a while back in not allowing workers to wear the traditional ppe. at the white house ideation session, participations

discussed that ppe limitations. a hese will be evaluated by team of experts -- niosh will evaluate the prototypes. five, the supply chain issue. we do not often think about that as a research question, but i wanted to put it out there today because it is a complex question. we need to determine what metrics we're going to use in the supply chain management. we are starting to see sorted is now in certain items. want that to happen. how can we prevent it from happening? so what we're trying to do as a pilot surveillance system for loped and implemented the four hospitals in terms respiratory protection devices -- evaluating performance differences between new devices, age -- we're developing more ppe recommendations for additional ebola referral centers as they are added to the system. the three biological behavior

knowledge generation priorities the table put on today -- how long does the remain viable and services, including pbe. what types of different factors in contact times i needed to inactivate the ebola virus. so, certainly this issue about how long this virus remains viable on different services on ppe is one y, that we are certainly interested in. viral penetration through protective clothing -- how long does that last and what contact times. effect ypes of different and contact times -- contact times and

are needed. different issues in disinfectants, the their tration, and contact times -- how long do they need to remain on the surface in terms of it infection and how studies inform. the best tly, what are detective methods to detect evil on services -- ebola on services and ppe. i want to stress that research and control done laboratory settings. so it is and important for step to make sure that this type of sampling method is reliable, is validated before one roundups of field studies. i think that is where i will and it. i want to thank everybody who helped to prepare this presentation, especially the

people at the national protective laboratory in pittsburgh, pennsylvania. thank you. [applause] for that, john howard. where next bringing forward michael hutchinson. the chief medical officer from the department of labor. welcome. dr. goldman for the invitation to present some that come out of the occupational safety and health administration. the meeting comes, obviously, at a very timely and opportune reflects to our surprise a failure of planning. the response and recovery

implies that, here, in the response, we have done adequate response in an mitigation. that does not appear to be the case. we wonder whether there's some how on and thinking through we approach this, given the 1999 ns from august agents on biological the h1n1 ars and pandemic -- there may be an overlap between activision will help an infectious disease and failing to think through the in the of -- of work real world. it is worth test, remembering the lessons from sharps injury prevention. healthcare workers -- an and the reality workers early on as proved say, tant in some things, and devices es

with sharps. we do not do that here, as i will get to in a minute. let me think with you about some problems for hospitals and problems outside of hospitals. they the last 12 years, have managed the ebola successfully in many countries. some of the guidance was incorporated into the who lessons. some of the other lessons were not disseminated as effectively as they might have been. so the training method, for donning with observering -- and the implications of ebola treatment unit designs -- how to manage the real world -- is an issue. although most hospitals now few weeks n -- a

late -- it turns out that many of those hospitals are still struggling. not just with the process flow, but the real infrastructure. now many hospitals right are doing construction to replace walls, to figure out how to manage airflow, and how to have enough space to stage doffing with a body without the aminating the body -- who is doffing equipment or the rest of the room in which they are moving around. so how much space is needed in reality? how much training is really needed to doff safely? there are a number of courses ucla just looked at how effective doffing training with 16 hours over 10 days would be -- an fewer than the staff were actually able to pass their internal test.

that suggest that doffing training is pretty hard and if you remember the msf focus on doffing and buddy observation, the question of why -- why to physicians who came back so contaminated and became ill is not so surprising. if you are not used to doing something regularly and energetically, it is just not going to work that well. what are effective ways and computing strategies to manage waste in a modern hospital? heard about y has the ebola management strategy at emory with an enclave unit on the word. have a ospitals do not large autoclave, so the question of how to move that waste around has generated new discussions between had it been t

involved. these are all failures of preparedness and thinking through -- upfront -- how to manage something. what our just-in-time management strategies for hospitals? should the nurse at the triage in infectious disease consult or initiate the hospital command system? is emergency management stuff and most hospitals had not thought that through. their lesson for us -- is there a lesson for us. given the approach, where are the boundaries between use of surgical masks and respirators? the cdc has, meanwhile, put 95s and paprs up.

there are paprs with -- many hospitals exit purchase those. in fact, needed for appropriate protection? and then, finally in hospitals, what is the perspective of frontline healthcare workers on managing the infrastructure? it turns out -- if you read documents -- the nonhierarchical team approach protection re worker and leadership commitment are not likely essential. how do we, as a system, get to involving healthcare workers early into that process? than thinking about some problems outside of the hospital. where does the virus migrate as we think through use and destruction?

so, as we think through the critical infrastructure and resource sectors, where are -- either processes or engineering failures generate exposure -- how do airplane cleaners clean toilets and airplane? how to truck drivers transporting waste deal with accidents? so thinking goes through in a copy hands of approach is essential. what kinds of ppe are necessary in each one of those processes. and then, what do we know about the level of ppe necessary for each of those? finally, based on all this, do we think -- how can we better to find ways that the public health system communicates these risks to ways that they

understand and act appropriately? the lessons ber we m sars in toronto if have not invested the working the risk and developing the protection strategies. in fact, they will not come to work. that was one of the big toronto lessons. we create a safety culture that lets people feel comfortable and let them come to work. thanks. [applause] this o the last member of panel, paul lemieux, was with the epa office of research and development. the national homeland security research center. welcome. >> thank you, dr. goldman.

i'm honored to be your. i am primarily -- i am honored to be here. i am primarily going to be talking about treatment waste, but this is a big incident that involves many different considerations that impact other considerations like how infection ach the control affects how the waste is generated. so everything affects everything else in the be uation and we need to able to -- to be thinking about all of them at the same time. talk about waste management, there is a number steps two waste management, some of which can result in potential exposure to the waste management workers. and there are technical of ues associated with some them as well. i'm going to focus on the aspect of it, but

people need to remember that package e people who truck uff up, there are drivers who transported, when it arrives at the treatment facility, they may have to open up the packages. dot has fairly stringent to package s for how category a bioagents. then you have to transport to your ultimate disposal industry. there has been a stigma attached to some of this waste is not a technical issue, but the landfills are typically publicly held companies. in the stock market can fluctuate based on unreasonable assumptions, so

a legitimate concern about their business assets and their stock price. when we talk about the waste to be do with, you have the personal effects of the people -- the conventional medical waste. nonporous materials, typically. but in this situation, we are of porous have a lot scrubs, s -- linens, pellets, mattresses -- especially if you have to cleanup of contaminated spaces, of public transportation vehicles, there is decontamination residues cleaning up th the premises. they may not be contaminated had disinfected in them, but they may be considered to be a rec-hazardous waste.

you have issues with cleaning up pats. potentially a lot of ways to do it. we e limited information have now suggests that these to ients generate about 30 40 times they amount of that normal patients generate. so we're looking maybe 35 gallon drums packed in 90 gallon drums. is a lot of material that has to be hauled around. is a lot of risk of workers who have to handle these. when you talk about management waste, there's all sorts of different aspects that simultaneously have to be considered.

how appropriate is the facility? is the facility available? does it have the capacity? the e will continue with ebola workshop shortly. to the white house with an announcement by president obama. >> i rely on my cabinet every day to ensure that we are not just getting the job done, but we are making progress for the american people. and in a country that is built the rule of laws, there are few office is more important than that of attorney general. the attorney general is the people's lawyer. chief law tion's enforcement officer, the person in this position is

enforcing our federal laws. protecting her civil rights. oversees rney general a vast portfolio of cases, including counterterrorism, voting rights, public corruption, white-collar crime, judicial recommendations, and policy reviews. all of which have impact on lives of every american and shape the life of our nation. as i stood back in september decided to step down -- i'm enormously holder in his c position. is one of the longest-serving attorney general's in american history and one of our finest. aircraft to this job will believe that justice is not just an abstract theory, but a living and breathing principle. is about how law interacts with the daily lives of our people. whether we can provide for families.

whether we feel safe in our communities and welcome in our country. whether the words that the founders that the paper 238 to everyone of us. so, thanks to eric, our is safer and freer. and more americans, regardless or gender religion or creed or sexual orientation receive fair , and equal treatment under the law. i cannot be prouder of eric. and i cannot be prouder that i can announce somebody who shares that equal passion under the law. nominee for the next attorney general, general loretta lynch. [applause]

i also, by the way, want to thank the chair of the senate judiciary committee for being here on a saturday to show his support. [applause] it's pretty hard to be more qualified for this job than loretta. throughout her 30-year career, she has distinguished herself as tough, as fair, and independent lawyer who has twice headed one of the most prominent u.s. attorneys offices in the country. she has spent years in the trenches as a prosecutor ,ggressively fighting terrorism fraud, cybercrime, all while vigorously defending civil rights. a graduate of harvard college and harvard law school, loretta rose from assistant attorney to

chief of the long island office, chief assistant u.s. attorney, and u.s. attorney. she successfully prosecuted the terrorists who plotted to bomb the federal reserve bank and the new york city subway. she has boldly gone after public corruption, bringing charges against public officials in both parties. she has helped secure billions in settlements from some of the world's biggest banks accused of fraud and jailed some of new york's most violent and notorious mobsters and gang members. one of her proudest achievements was the civil rights prosecution of the officers involved in the brutal assault of a haitian immigrant. loretta might be the only lawyer in america who battles mobsters and drug lords and terrorists and still has a reputation for being a charming people person. [laughter] that's probably because loretta does not look to make headlines -- she looks to make a difference. she is not about splash. she is about substance.

confidentt be more that loretto will bring person which are intelligence and passion and commitment to our priorities, including important reforms in our justice system. she has consistently proven her leadership and earned the trust of those she serves. since 2010, she has been a member of u.s. attorneys across the nation who advise the attorney general on matters of policy and has served as chair of that committee since 2013. it's no wonder that the senate unanimously confirmed her to be the head of the u.s. attorneys office in two separate situations -- once under president clinton, and once under my administration. it is my hope that the senate will confirm her a third time without delay. at every stage in her career, followed the ideals of justice she absorbed add a young girl. she was born in north carolina the year before black students

sat down at a whites only lunch counter, helping to spark a movement that would change the course of this country. the daughter of a school librarian and a fourth generation baptist minister, which meant that she knew when to be quiet. [applause] a little intimidating, being the daughter of a librarian and minister, but loretta rose on her father's shoulders to his church where students would meet to organize anti-segregation boycotts. she was inspired by stories grandfather, a sharecropper in the 1930's who helped folks in his community who got in trouble with the law and had no recourse under the jim crow system. i know that if he were here today, he would be just as proud of her as ensure her husband stephen is. i want to thank stephen, loretta's stepson ryan, her stepdaughter, and her other family members who came here today. we appreciate you guys agreeing to share her with the american

people a little bit longer. her life fighting for fair and equal justice that is the foundation of our democracy. i can think of no better public servant to be our next attorney .eneral let me introduce to you ms. loretta lynch. [applause] >> thank you, everyone, and thank you, first of all, mr. president for that kind introduction, but most importantly, thank you, also, askingr faith in me and to succeed and attorney general home i admire and to lead the department that i love. no one gets to this place, this

room, this podium, this moment by themselves. i also must thank attorney general eric holder for your support and friendship over the years. as well as by leading for -- by example and always, always pushing this department to live up to its name, and i want to thank chairman leahy, senior officials at the department of justice and members of the cabinet for being here today. to my colleagues in the u.s. attorney community and throughout the department on whose strength and wisdom i lean every day, thank all of you as well for your support both now and in all the work that we have ahead. and to my beloved office, the eastern district of new york, my professional home, you have twice now given me the privilege of being able to serve you and to focus on nothing but the protection of the american people. it has been a joy. it has been an honor, and i will carry you with me wherever i go.

of course, to my wonderful family, several of whom are here are me today, all of whom always with me in love and support. most especially, my parents who could not be here today but are watching, whose every thought and sacrifice has always been for their children. they have supported me in all of my endeavors as i have strived to live up to their example of service. the department of justice is the only cabinet department named , and this is actually appropriate because our work is both aspirational and grounded in gritty reality. it is both in no bling and profoundly challenging -- it's ng and profoundly challenging. i stand before you so humbled to have the opportunity to lead this group of people who work all day and well into the night to make that ideal and manifest reality all as part of their

steadfast protection of the citizens of this country. mr. president, thank you again for the faith you have placed in me. i pledge today to you and to the american people that if i have the honor of being confirmed i the senate, i will wake up every morning with the protection of the american people my first thought, and i will work every day to safeguard our citizens, our liberties, our right, and this great nation which is given so much to me and my family. you again, mr. president, mr. attorney general, and all of you. [applause] >> [inaudible] >> i think it is a wonderful day for them. [inaudible]

doing a great job on what was obviously a challenging mission. >> the president there making reference to the freeing of detainees in north korea. u.s. intelligence officials say two american citizens on their way home from north korea after their release from prison. loretta lynch, the president's selection for the next attorney general to replace eric holder. it is uncertain when her nomination will be taken up by the senate. politico writes that the account -- the accommodation could come during the lame-duck session. senator mitch mcconnell, who is expected to be the next majority leader in january, has said that the nomination should be considered in the new congress through regular order. both the house and senate returned wednesday to begin the remainder of the 113th session. as always, you can watch the

house live here on c-span, the senate live on our companion network, c-span2. now back to the national academy of sciences where on monday, the institute of medicine hosted and workshop. doctors and other professionals involved in the study and treatment of ebola presenting research data on the disease. >> there's some testing being planned by new york state dec to try to look at some of these issues. we need a good surrogate. you cannot be doing disinfection tests and waste management tests in a bsl4 facility. we do have something we can use that would belity appropriate for whatever type of experiments we are doing. wastewater issues -- how do you measure it in the wastewater? what is the fate of the organism as it goes from the point of generation down to the wastewater treatment facilities? as a ghost through the sewer,

you might have vector issues where the rats in the sewer might potentially pick something .p the idea of getting mobile capacity in order to not have to transport these items in this if you cankaging -- activate it on site, you can go through a much less rigorous waste packaging and waste management process. also, the potential for innovative treatment options would be nice, like microwaves. there's no data on those. and i have some resources. thank you. [applause] >> we have one last presentation. daniel bausch, professor at the tulane university health sciences center, and their .epartment of tropical medicine

he will be talking to us about observations from africa that agenda.rm a research thank you. >> thank you. thanks for inviting me, and thanks to all you for coming to listen. i would love to have time to delve into the many very fascinating scientific questions that come up, but my job here this morning is just to give you a glimpse of how things are going in west africa. we have had some opportunity, of course, with patience here in the united states to take some very valuable observations, but, of course, we hope not to have more opportunities. really, the research that needs to be done if we are really going to delve into this -- and the virus is in a difficult area of the world to work in in west africa, soaring going to give you a glance of how this is because most people, of course, have not really been on site.

i have not been on site in the last 21 days, fortunately, or i would not be here. idea is really getting an of the challenges and a glimpse of how things work here. so, first of all, we need people , and cj alluded to this -- and this is one of our biggest challenges. we take a country like sierra leone with a medical school was closed all during the war. after that, graduated about 10 medical doctors a year, and probably, i would guess half of those are drawn off to the brain drain to begin with, and some estimates have 20% of them having already died of ebola. you try to asked the question who will do this work, and of course, there is competition between the work that needs to be done and the public health response and patient care and research. we have a big problem. we tried to get around that with come back to will that. so do we use the local labor? how much of that is there? of course, we have international labor. this is a photo taken of the

first training we did last month, trying to get some of the international people trained to work in this, but of course, this is a difficult task as well, to get all those people trained and over there, and, you know, volunteers also. how many people have the time, the interest, to really go and take care of patients who might look like this? these are dangerous patients sometimes. it is hard work, stressful work, so trying to do this and be in a situation -- if you are a doctor in a hospital in the united states, and you tell your chief of staff that you want to go and work in west africa for a little while, difficult to begin with. they asked who is covering your patience while you are gone, how that is working. your wife or husband may not be real excited, and now, we are adding on 21 days where you are not working after you get back. labor both internationally and locally is a big challenge.

going out of order a little bit i mentioned, the 21 days added on, we need to fight against that and try to inject some reasoning into that. -- ithe infrastructure have been kind of not intentionally but found myself playing the role and little bit of a spoiler in some of the meetings like this. it's not that i am opposed to the research or clinical trials or anything like that, but sometimes there are some unrealistic expectations of just what we have and what it might take to do this in the field. settings.the sorts of this is an ebola treatment center. these vary a lot. here is kind of something that you might see in the beginning of an outbreak. very rustic settings. sometimes, unfortunately, still the rustic settings we have in west africa.

not what we want them to be, but just what we have with the capacity right now, and some of these are really much less treatment centers, but just places for someone to go, rehydrationt some solution, some tylenol, and a place to die out of circulation to not infect other people. when we have this sort of setting and then we contemplate something where we are going to do studies where we need to draw blood samples every four hours a cold chain and electrolytes in the sorts of things -- it's not that they cannot be done, so i do not mean to say that this cannot be set up, but i think we need to be realistic about some of the challenges that are ahead of us. .his is another photo this is a treatment center in sierra leone. is sierra leone. this one is in guinea. we would not like to have all these beds together. we would like to have separate rooms, but this is the sort of

place -- you may have read about it -- where the nurses were going on strike for gourley. we had a lot of health-care workers who were getting sick and dying in this area. we had times when we had 70 patients with ebola here and myself and one other health care worker to try to take care of them. when you talk about, again, trying to do research to say we need to draw blood, we need to monitor this or that, when you have the sort of setting, of course, very difficult, so we the capacity.se it can be like this. thing that sort of we would like. today, we would not like to have those beds altogether, but sometimes that's the only choice we have. a lot has been discussed about personal protective equipment, and leaving the safety issues aside,t is the right ppe no matter what you use, this is , so cumbersome work to do

if you use this, you can stay in for about an hour and a half really until your core temperatures get up to potentially dangerous levels. this is closer to what would be .dvocated by who we recently instituted a process to have new guidelines that came out yesterday. you might be interested in looking this up, and of course, there the obama challenge to try to innovate into new things beyond that. regardless, this is not the sort of setting where you can just say, "let me go in and work for five hours at a time and take all the blood samples i want." it is cumbersome and stressful work, and there are other issues in place. this is the mobile laboratory .et up the european union .his was in guinea these exist in a couple of different places.

cdc, european union, public butth agencies of canada, of course, they are mobile laboratories, really meant for diagnostic purposes. right now, they have many, many sepals coming in. not only is it sometimes the capacity of the treatment center that is overrun, but the capacity of the laboratory as well, so we have the same need to thinke we of the personnel who will be working in these laboratories and whether we can dedicate them to the research, and are their priorities between research and the just routine public health diagnostics that need to be done. also, just an example trying to monitor and take some of these in the laboratory. we were using this device in guinea. some of you may be familiar with this device. turns out it does not really like the heat and humidity in west africa, so we really had a difficult time using this and most of the places. you can play with it and get it to work.

you can put it on a bed of eyes, but how many beds of ice to you theseeadily available in places? that's not the sort of thing that is routinely there, and electricity is not a given. running water is not a given. these things get set up imsf, which is the group used to doing the- that set up by msf, group that is used to doing it, but other groups can do it as well. which youat piccolo, put on the tabletop, is a little bit better for this. not quite as sensitive for the heat and humidity. he pointed doing research is we you to collect data, but have to have a way to get it outside the ward. ago are the days years where i used to just throw the patient charts out the window, spray them with bleach, and let the sunlight hit them for a while and then move on. i don't think we can do that anymore. so we have to have ways -- a little bit higher tech ways, and

this can be done using cell phone technology and tablets and different things and electronic transfer, so it is possible, but again, there are many steps we need to go through, and again, you can see the gloves that this person is wearing. it is not that easy to write all this stuff down in the heat and all the things going on. this is an example where people are giving the information desk there given the information on the patients -- they wrote it down inside, and they adjust recounting it for other people who could write it down, so there are other ways to do this. then, ethical considerations -- approvals, and hopefully, rapid approvals. they do have ethics committees, but not necessarily ones that are used to really sitting and expediting these things rapidly. i think that is being approached these days because of what is going on. to placebo or not placebo is a

huge, very contentious issue and trying to find the right balance of really what is research that we need to do -- obviously, talking about therapeutics and vaccines here. what is the research we need to do to collect the information? clinical trials that are formally done so we come out of this with some solid data, but the expectations across west africa, which are much more in compassionate use. a month and ang half ago now, and many representatives from west africa met in the initial stages to try to figure out how we go forward with some of the use of potential therapeutics and vaccines, and i can tell you all the people from west africa think the afternoon or evening probably had a call from the minister of health asking which when they chosen as the suitcase full. is it there today or will it come tomorrow? they are not thinking so much

clinical trial, but thinking -- where are the drugs to help people? an understandable way of thinking. lots of logistics getting to the site. of course, this takes a lot of vehicles, a lot of airplanes to get to remote areas. this is using bicycles that were unloaded to do surveillance. that is one of the things also that is not mentioned as much as kind of the operational research we need to improve. surveillance is another area that needs to be approached, but again, there is a strain on resources because this vehicle is needed for the surveillance, but it is also needed really to get your research staff around and to do the different things on site, so those are challenges. then, in many of these places, the physical security -- you have already been this. there were some health-care workers that were killed in guinea last month. i can tell you some stories from

guinea and sierra leone of some tense moments. i think everybody who has been on site has a few of those stories, especially when we have sometimes a resistant population . one of the ideas that is free quickly spread around about that resistance is that we are there -- ebola was either created or intentionally produced for people in authority from overseas from foreigners to come in and do research on people, and now when we are doing research on people, how does that feed into it? of course, we want to an will do ethical research, but we have to be aware of the perception of that, and there are some issues we have been struggling against. then what do you do if one of gets sick? h staff you need a backup plan. are they going to get cared for on-site? will they be evacuated to the united states? there are significant costs and logistical implications to all of that. we cannot necessarily send people -- if you send a bunch of people into a battle zone, then

here and there, some buddy gets shot, so you have to really be ready for that. while i do think we can do this safely, i do think that the ppe can work, but it's not the sort of thing that -- as jim said earlier, the dallas hospital -- it's not the sort of situation where you want to say, "here is your patient with ebola, here is your ppe, you have two hours to train." advance.to think in i mentioned societal resistance and cultural barriers. language barriers -- first of all, guinea is francophone. liberia and sierra leone are at lafond, although if you get into rural areas, some of your staff, depending on the training, it's common that people speak much more their local languages, rather than even english, even though english is the national language of some of those countries. there are cultural and linguistic areas to get over. i think i did it all in 15 minutes or close to it, so thank you very much. [applause]

>> ok, so, we have some time for questions and discussion and to engage our panel, and there are microphones placed in key locations. please come forward. i wanted to start with a question, and i am kind of inspired by a couple of the presentations. what it has to do with is for the purposes of working on issues like personal protective equipment, disinfection, waste , has any thought been given to what is an appropriate inrogate for the ebola virus terms of its behavior, survival under various conditions that does not require a psl for -- .sl4 laboratory facilities

two people have any ideas about that? >> there is a species of ebola which is thought not to be pathogenic to humans and could from 4.raded in addition, and ebola virus has been produced by genetic engineering that lacks the genes .o ward off i cannot imagine any institutional review board giving permission to use it. >> other ideas about that? pseudo-type various viruses that could potentially be used. you do always get into the

question of you do those experiments and then say yeah, but does it react the same way as the real virus? that would be another idea. offrom the point of view doing studies for ppe, we would like a surrogate that fluoresces . surrogates that epa is using with waste, which are bacteria, which is not appropriate at all in terms of characteristics. go ahead. >> part of the problem is the surrogate needs to be selected for the type of experiments you want to do. if you want to look at persistence on environmental matrices, you may want to look at one surrogate. if you want to look at how it interacts with bleach, you might look in a totally different surrogate. if you want to look at thermal incineration, you might want to look at a different one. selecting the right surrogate is difficult, and it will not be one bug fits all.

>> just a follow-up on that, as dr. howard pointed out, having the surrogate -- testing claiming of an air purifying rubber mask is very different that.hinking about what you are trying to do with testing -- are you trying to evaluate whether the filtration effectiveness works or whether contaminates the skin is a very different question. inking through what question you are asking requires defining what you want in a surrogate. >> there are commercially available fluorescent powders that are not visible to the eye until they are hit with uv

light. it seems to me like that would be a very vaginal adjunct to training people in doffing their gear if they put on their gear and then had this powder applied, and then they were fluoresced, after you got the gear off, you could see where some of the brakes might occur. >> we have the first question at the microphone. if you could please identify yourself. the microphone is a little bit high, isn't? >> that's all right. i think it's fine. thank you. healthe safety and director for afl-cio, and thanks to everybody for being here and your great presentations. last presentation just really brought it all home in terms of the crisis being faced. one of the things that is really important as we think about

research in the same way that we think about how we are going to stop the virus, we have to look at africa. we have to look first and foremost at africa for what are the research needs as well, and one one area that would be very to focus on -- 527 healthcare workers who have gotten sick and the 250 word died. to have any more on the information? who they were? with their occupations were? it does seem that that will be at the heart of response. much as we can s about the exposures. as michael hutch said, go to the frontline workers in africa and i know what they need. what are the questions that need to be answered for them for them